Compression Fractures

eradiology.bidmc.harvard.edu

Compression Fractures

Eleanor Adams

Gillian Lieberman, MD

Compression Fractures

Eleanor Adams

Harvard Medical School Year IV

Gillian Lieberman, MD

September 2006


Eleanor Adams

Gillian Lieberman, MD

Overview

• Spine Anatomy

• Thoracolumbar Fractures

• Cases

Compression Fractures, Ddx

• Radiologic Tests of Choice

• Treatment Options

Cedars-Sinai Cedars Sinai Medical Center, www.csmc.edu/7133.html

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Vertebral Body

Eleanor Adams

Gillian Lieberman, MD

Vertebral Anatomy:

Overview of Thoracic Vertebrae

Pedicle

Spinous

Process

Lamina

Vertebral Body

Pedicle

Transverse

Process

Spinous

Process

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Transverse

Costal

Facet

Eleanor Adams

Gillian Lieberman, MD

Vertebral Anatomy:

Superior

Articular

Facet

Overview of Facets

Superior Costal Facet

Inferior Costal Facet

Superior

Articular

Facet

Transverse

Costal

Facet

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Eleanor Adams

Gillian Lieberman, MD

For Comparison…

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Eleanor Adams

Gillian Lieberman, MD

Normal

Frontal

Radiograph

• Need to Assess:

• Quality Control

• Soft Tissues

• Alignment

• Bones

• Cartilage

Spinous Processes

Pedicles

Intervertebral

Disc Space

PACS, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Normal Lateral

Radiograph

Vertebral Body

Intervertebral Disc

Space

Spinous Process

Pedicle

PACS, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

1.) Anterior column

Spinal Columns

– Anterior longitudinal ligament, anterior half of the

vertebral body, disc, and annulus

2.) Middle column

– Posterior half of the vertebral body, disc, and

annulus, and the posterior longitudinal ligament

3.) Posterior column

– Facet joints, ligamentum flavum, flavum,

the posterior

elements and the interconnecting ligaments.

Panjabi et al. 1995

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Eleanor Adams

Gillian Lieberman, MD

Spinal Columns

Anterior Column

Middle Column

Posterior Column

PACS, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Spinal Columns

• The spinal canal and cord are located in the

Posterior Column, adjacent to the Middle

Column

• Therefore, fractures in elements in the Middle

or Posterior Columns have the potential to

impinge on the spinal canal and cord

• For this reason, Middle and Posterior Column

fractures are considered unstable.

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Eleanor Adams

Gillian Lieberman, MD

Types of Fractures

Type of Fracture Column Affected Stable vs. Unstable

Compression/Wedge Fracture

Anterior Only Stable

Burst fractures Anterior and Middle Unstable

Fracture/Dislocation Anterior, Middle, Unstable

Injury Posterior

Seat belt fractures Anterior, Middle, Posterior

Unstable

http://www.spineuniverse.com/displayarticle.php/article1441.html

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Eleanor Adams

Gillian Lieberman, MD

Patient LI

• Patient LI, an 82 year old female with

osteoporosis and mild dementia, presented to

her physician with lower back pain and

posterior leg pain

• Back pain present for 1-2 1 2 months

• Difficulty getting out of bed in morning due to

pain

• Loss of appetite because of intensity of pain

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Eleanor Adams

Gillian Lieberman, MD

Patient LI

• Given that Patient LI had

osteoporosis, her physician suspected

she had a compression fracture.

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Eleanor Adams

Gillian Lieberman, MD

Compression Fractures

• Osteoporosis is the leading cause of vertebral

compression fractures in the U.S.

• 700,000 per year in U.S.

• Affect 25% postmenopausal women

• Incidence expected to increase fourfold in next 50

years

• Why Important?

– Pain can lead to immobility and further disability

– 15% increased mortality rate

– Preventable in most cases

Old et al., 2004

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Eleanor Adams

Gillian Lieberman, MD

Compression Fractures

• Most commonly occur T8-L4 T8 L4

• Anterior or lateral flexion causes

failure of Anterior column only

• Middle column and Posterior column

are undisrupted

• Middle column may act as hinge

• Can be further classified by the Denis

Classification according to endplate

involvement

PACS, BIDMC

A

M

P

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Eleanor Adams

Gillian Lieberman, MD

Differential Diagnosis

• Atraumatic Compression Fracture:

– Osteoporosis

• Senile/Post-Menopausal

Senile/Post Menopausal

• Steroids

– Osteomalacia

– Pagets Disease

– Multiple Myeloma

– Hyperparathyroidism

Cedars-Sinai Cedars Sinai Medical Center, www.csmc.edu/7133.html

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Eleanor Adams

Gillian Lieberman, MD

What is your initial imaging test of

choice?

• Plain frontal and lateral radiographs are the

initial studies of choice

• In 20-30% 20 30% cases multiple fractures are present

• Important to image entire spine

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Eleanor Adams

Gillian Lieberman, MD

Radiograph Findings of

Compression Fractures

• Anterior height of vertebral body is diminished

• Posterior height of vertebral body is normal

• No anterior or posterior translation of vertebral

bodies

• If anterior compression is >40% when

compared to posterior vertebral body height,

suspect burst fracture

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Eleanor Adams

Gillian Lieberman, MD

Patient LI:

Frontal Plain

Radiograph

• Dextroscoliosis centered

around L2-3 L2

• Multilevel degenerative

changes

• Endplate sclerosis

• Multilevel facet

hypertrophy

• Increased lucency in

vertebral bodies

Compression fracture of

L1

PACS, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Patient LI: Lateral

Radiograph

Compression

fracture of the L1

vertebrae causing

focal kyphosis

• There is a 5 mm

anterolisthesis

of L5 on S1

Compression

Fracture of L1

Normal

L2

PACS, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Comparison A:

Lateral Radiograph

• 71 year old with a history of

osteopenia who presented with

mid-lower mid lower back pain

Compression fracture of

anterior of the T11 vertebral

body

• Demineralization

present

Compression

Fracture of T11

Normal T12

Courtesy Dr. Yamada, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Comparison B:

Lateral Radiograph

• 82 year old who

suffered a mechanical

fall at her assisted living

home

• There is approximately

a 15% loss of anterior

vertebral body height of

T12

Compression

Fracture of T12

Courtesy Dr. Yamada, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Role of Additional Imaging

• Role of CT:

• Use to identify fractures not well visualized on plain film

• Allows for visualization of middle and posterior elements

• Can distinguish between compression fracture and burst fracture

• Can also reveal spinal canal narrowing

• Disadvantage:

• Can’t detect horizontal fractures of vertebral bodies or pedicles pedicles

well

• Role of MRI:

• Recommended when patient has suspected spinal cord

compression or other neurologic symptoms

Old et al., 2004

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Eleanor Adams

Gillian Lieberman, MD

Patient LI

• Given that Patient LI reported posterior leg

pain, her physician decided to order an MRI to

assess the spinal cord and spinal canal

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Sagittal

Eleanor Adams

Gillian Lieberman, MD

Patient LI: T2 MRI

Axial

PACS, BIDMC

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Eleanor Adams

Gillian Lieberman, MD

Patient LI: MRI Findings

• The conus terminates at L1

• No evidence for internal expansile mass

• Dextroscoliosis of the lumbosacral spine with

apex at L2/3

• L1 compression fracture

• Spinal stenosis

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Eleanor Adams

Gillian Lieberman, MD

Treatment Options

• Non-operative Non operative treatment is the standard

– Pain medication (observe bowel motility)

– Brief rest (2-3 (2 3 days), encourage early ambulation

– Avoid compression overloads for 2 months

– Muscle relaxants, external back braces, and

physical therapy may also help

• If patients do not respond to conservative tx: tx

– Percutaneous Vertebroplasty

– Kyphoplasty

Singh et al., 2006

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Eleanor Adams

Gillian Lieberman, MD

Summary

Compression fractures common in elderly population

Compression fractures are caused by failure of the

anterior column only

• Initial imaging modality of choice is plain film

• Can use CT or MRI if have concern that the middle

or posterior columns are involved, and to evaluate

spinal cord

• Treatment is usually conservative

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Eleanor Adams

Gillian Lieberman, MD

References

• De Smet AA, Robinson RG, Johnson BE, Lukert BP. Spinal Compression

Fractures and Osteoporotic Women: Patterns and Relationship to Hyperkyphosis.

Hyperkyphosis.

Radiology 1988; 166:497-500.

166:497 500.

• Kroth PJ, Murray MD, McDonald CJ. Undertreatment of osteoporosis in women,

based on detection of vertebral compression fractures on chest radiography.

radiography.

Am J

Geriatr Pharmacother 2004; 2(2):112-118.

2(2):112 118.

• Old JL, Calvert M. Vertebral Compression Fractures in the Elderly. Elderly.

Am Acad Fam

Phys 2004: 69(1):111-116.

69(1):111 116.

• Panjabi MM, Oxland TR, Kifune M, Arand M, Wen L, Chen A. Validity of the

three-column three column theory of thoracolumbar fractures. Spine 1995; 20(10):1122-1127.

20(10):1122 1127.

• Singh AK, Pilgram TK, Gilula LA. Osteoporotic Compression Fractures: Outcomes

after Single versus Multiple-Level

Multiple Level Percutaneous Vertebroplasty.

Vertebroplasty.

Radiology 2006;

238(1):211-220.

238(1):211 220.

• Yuh WT, Zacher CK, Barloon TJ, Sato Y, Sickels WJ, Hawes DR. Vertebral

Compression Fractures: Distinction between Benign and Malignant Causes with

MR Imaging. Radiology 1989; 172:215-218.

172:215 218.

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Eleanor Adams

Gillian Lieberman, MD

• Special Thanks to:

Acknowledgements

• Gillian Lieberman, MD

• Maryellen Sun, MD

• Kei Yamada, MD

• Pamela Lepkowski

• Larry Barbaras

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